Grave's disease as a manifestation of immune reconstitution inflammatory syndrome in an HIV-infected child on highly active antiretroviral therapy: A case report.

Introduction: Immune reconstitution inflammatory syndrome (IRIS) can unmask autoimmune disease after antiretroviral therapy (ART), and Graves' disease has been reported as a late autoimmune manifestation, though pediatric cases are exceptionally rare. Case presentation: A 9-year-old Ethiopian boy with vertically acquired HIV, diagnosed at age 6 during an acute illness, had presented at that time with profound immunosuppression (CD4 23 cells/mm³, HIV RNA ∼150,000 copies/mL) and was started on combination ART. He achieved sustained virologic suppression and marked immune recovery (CD4 >1800 cells/mm³). Thirty-three months after ART initiation he developed a six-month history of weight loss, palpitations, increased appetite, night sweats and progressive bilateral proptosis. Examination showed tachycardia, lid retraction, lid lag and a diffusely enlarged, soft, non-tender goitre. Laboratory testing revealed suppressed TSH and elevated free T4; thyroid ultrasound demonstrated a diffusely enlarged, hypervascular gland. Thyroid autoantibodies were not available. A clinical diagnosis of Graves' disease in the context of IRIS was made. Management and outcome: ART was continued. He was treated with carbimazole and propranolol with close endocrine and infectious-disease follow-up. Symptoms resolved, heart rate normalized and thyroid function tests returned to the euthyroid range, allowing down-titration of carbimazole to a maintenance dose. Conclusion: This case illustrates that Graves' hyperthyroidism may present as a late IRIS manifestation in children with profound immune recovery after ART. Early recognition, standard antithyroid therapy and continuation of ART can achieve good outcomes.